Delirium in Preverbal Children: Guest Post by Luisella Magnani, In Memory of Giampaolo

This is a very lyrical guest post by Luisella Magnani, Professor at the College of science of Linguistic Mediation of Varese, disciplines General Linguistics, English literature, modern history; Researcher at Università Cattolica del Sacro Cuore of Milan; Professor of Aesthetics at the Università Cattolica del Sacro Cuore in Brescia. See the translated link about Luisella Magnani at Professor Magnani got in touch with me by e-mail about my post on delirium in children, Delirium in Children-Praise for the Paladins of Pediatrics « The Practical Psychosomaticist: James Amos, M.D. She is grieving the death of her little nephew, Giampaolo, who succumbed to cancer and suffered delirium as well, and through the new discipline described herein and through poetry is finding a way through the deepest of sorrows. I hope I’ve transcribed the professor’s guest post as accurately as possible through the translation from Italian to English (thanks to the “miracle” of the Microsoft Translator, I suspect) so that it speaks both to the heart and the mind. I don’t speak Italian, so I hope I have not slaughtered the meaning of this tribute and this mission in the study of preverbal pediatric delirium. I did my best to preserve the sense and perhaps some of the music.

Professor Magnani is developing a project for the Psychology Department, Catholic University in Milan in which two pediatric delirium detection tools will be studied. One of them is the pCAM-ICU, mentioned in my post,  Delirium in Children-Praise for the Paladins of Pediatrics « The Practical Psychosomaticist: James Amos, M.D. The other is the Pediatric Anesthesia Emergence Delirium (PAED) scale to measure emergence delirium in children (see reference below). Dr. Magnani plans to construct a scale to measure delirium in preverbal children, the preverbal pediatric emergence delirium (pPED) scale. As I understand it, the idea is that preverbal children can communicate by gesture and that it’s possible to connect with them through signing.

“…no parent can see his/her little child tearing his hair out and crying, crying in his inconsolability, because he is unable to express himself. No parent must say “This is
not my child anymore. Where is my child? Why has he so changed?”–Professor Luisella Magnani on delirium in preverbal children


                   originally written onSunday, 17th October 2010, 5.00 pm

                                         by  Luisella Magnani

Linguistics wants to have a new mission. Linguistics wants to be at the very complete disposal of Oncology and Psychology in order to help preverbal and nonverbal children in pain from cancer. When these three disciplines are joined together in order to create a new event, we may understand children in pain in order that they feel understood (Claire Vallotton).  The nature of a word, its composition and its expression is a sweet and soft gift to the child. The voice enters him and lives inside him as a therapy along with other therapies. The power of mind, the power of word-sign-and-gesture, and the power of pain are interlinked within the space and time of the OncologicPsychoLinguistics, in order to create adherence, coherence, constancy, and consistence to and for and in the child in pain. This discipline was born on October 17, 2010, at 5.00 pm. On that day, at that time, a 19-month-old preverbal child afflicted with cancer died. It’s for him that this discipline was born and it’s in favor of and for love of all the other preverbal and nonverbal children suffering from cancer that this discipline lives. The concreteness of a word is so extraordinary. It’s bread which nourishes, and pre-verbal children in pain are fed by that word and they drink that word. The softness and sweetness of thinking translated into a sign and a gesture is a presence, the concreteness of presence before and within a child in pain.

Linguistics wants to be at the service of these two disciplines. This linguistic approach is so important that it becomes the source of a new behaviour for every kind of person who cares.   Oncology is no more alone, Psychology is no more alone. Being in Language, because you live it. A new language of being, a new way of being-language, to live it and be conscious that every spoken word feeds the other’s heart, mind, and body.

The natural action of a Child-Sign, the interpretation of the sign is life for a child in pain. When the child notices that your observation is so very deep, this observation becomes for the child an action built just for him. It seems that the cake of pain is divided into many slices, and these slices can be shared, and pain is no more a great burden on the little child’s shoulders. The child wants his sign collected, picked up, kept and held. Within the observation, [ob – serbāre, to keep on behalf of], attention and interpretation, there lives the action of being just for that child in pain. And this action becomes a non-pharmacological approach for detecting the emergence of delirium in preverbal and nonverbal children suffering from cancer.   If … a minute of pain is an eternity for most children (Leora Kuttner, 2010) and  by “listening” to infant signs, parents, practitioners and scientists gain insight into individual infants (Claire Vallotton, 2011), then that insight into individual infants in pain means to understand deeply and immediately, consequently converting understanding into best practice. It’s within this dimension that I am writing a project whose title is “Pediatric Delirium in Preverbal-and-Nonverbal Oncologic Children”. “Non-Pharmacological Management” (September 2012), is a project wherein the OncologicPsychoLinguistics finds its application creating a new scale for preverbal pediatric emergence delirium or pPED.

Submitted for posting: Wednesday, 8th August 2012                                                                                

Important Links to Luisella Magnani’s Resources:

Luisella Magnani A Child in Pain: What Health Professionals Can Do to Help [Paperback]: Leora Kuttner: Books A Child in Pain: How to Help, What to Do (9780881791280): Leora, Ph.D. Kuttner: Books

Babies open our minds to their minds: How “listening” to infant signs complements and extends our knowledge of infants and their development – Vallotton – 2011 – Infant Mental Health Journal – Wiley Online Library


SIGNING WITH BABIES AND CHILDREN: A Summary of Research Findings by Claire Vallotton, Ph.D. – Bing

Sikich, N. and J. Lerman (2004). “Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale.” Anesthesiology 100(5): 1138-1145.

BACKGROUND: Emergence delirium has been investigated in several clinical trials. However, no reliable and valid rating scale exists to measure this phenomenon in children. Therefore, the authors developed and evaluated the Pediatric Anesthesia Emergence Delirium (PAED) scale to measure emergence delirium in children. METHODS: A list of scale items that were statements describing the emergence behavior of children was compiled, and the items were evaluated for content validity and statistical significance. Items that satisfied these evaluations comprised the PAED scale. Each item was scored from 1 to 4 (with reverse scoring where applicable), and the scores were summed to obtain a total scale score. The degree of emergence delirium varied directly with the total score. Fifty children were enrolled to determine the reliability and validity of the PAED scale. Scale validity was evaluated using five hypotheses: The PAED scale scores correlated negatively with age and time to awakening and positively with clinical judgment scores and Post Hospital Behavior Questionnaire scores, and were greater after sevoflurane than after halothane. The sensitivity of the scale was also determined. RESULTS: Five of 27 items that satisfied the content validity and statistical analysis became the PAED scale: (1) The child makes eye contact with the caregiver, (2) the child’s actions are purposeful, (3) the child is aware of his/her surroundings, (4) the child is restless, and (5) the child is inconsolable. The internal consistency of the PAED scale was 0.89, and the reliability was 0.84 (95% confidence interval, 0.76-0.90). Three hypotheses supported the validity of the scale: The scores correlated negatively with age (r = -0.31, P <0.04) and time to awakening (r = -0.5, P <0.001) and were greater after sevoflurane anesthesia than halothane (P <0.008). The sensitivity was 0.64. CONCLUSIONS: These results support the reliability and validity of the PAED scale.

Smith, H. A., J. Boyd, et al. (2011). “Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.” Critical care medicine 39(1): 150-157.
OBJECTIVE: To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. DESIGN AND SETTING: A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. PATIENTS: A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. INTERVENTIONS: None. MEASUREMENTS: Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. RESULTS: A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (kappa = 0.96; 95% confidence interval, 0.74-1.0). CONCLUSIONS: The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.